3. Provide notice in writing when a Claim for benefits has been denied which notice shall set forth the
reasons for the denial and the right to a full and fair review of the denial under the terms of the
Benefits Booklet and shall otherwise satisfy applicable regulatory requirements, including those of
ERISA, governing the notice of a denied Claim.
c. Pursuant to Section 405(c)(1) of ERISA, Employer delegates to Anthem fiduciary authority to determine
claims for benefits under the Plan as well as the authority te act as the appropriate fiduciary under Section
503 of ERISA to determine appeals of any adverse benefit determinations under the Plan. Anthem shall
administer complaints, appeals and requests for independent review according to Anthem's complaint and
appeals policy, and any applicable law or regulation, unless otherwise provided in the Benefits Booklet. In
carrying out this authority, Anthem is delegated full discretion to determine eligibility for benefits under the
Plan and to interpret the terms of the Plan. Anthem shall be deemed to have properly exercised such
authority unless a Member proves that Anthem has abused its discretion or that its decision is arbitrary and
capricious. Anthem is a fiduciary of the Plan only to the extent necessary to perform its obligations and
duties as expressed in this Agreement and only to the extent that its performance of such actions
constitutes fiduciary action under ERISA. Anthem shall not act as the administrator of the Plan nor shall it
have any fiduciary responsibility in connection with any other element of the administration of the Plan.
Anthem shall charge Employer the fee described in Section 3.C of Schedule A for any independent review
conducted pursuant to this provision.
d. Anthem shall have the authority, in its discretion, to institute from time to time, utilization management, case
management, disease management or wellness pilot initiatives in certain designated geographic areas.
These pilot initiatives are part of Anthem's ongoing effort to find innovative ways to make available high
quality and more affordable healthcare and will apply equally to Members of both insured and self-funded
plans. A pilot initiative may affect some, but not all Members under the Plan. These programs will not
result in the payment of benefits which are not provided in the applicable Benefits Booklet, unless otherwise
agreed to by the Employer. Anthem reserves the right to discontinue a pilot initiative at any time without
advance notice to Employer.
e. Anthem shall perform recovery services as provided in Article 13.
f. Anthem shall issue identification cards to Subscribers and/or Members, as applicable, and the content and
design of the identification cards shall comply with BCBSA regulations.
g. Anthem shall provide certificates of creditable coverage as required by the Health Insurance Portability and
Accountability Act of 1996 ("HIPAA") with respect to Members’ participation in the Plan. Employer agrees to
promptly provide Anthem with any information relating to a Subscriber's employment history as may be
necessary for Anthem to provide the certificates of creditable coverage.
h. Anthem shall provide Members and potential Members access to an online directory of Providers
contracted with Anthem ("Provider Directories"). Such Provider Directories shall also be available and
distributed in booklet format upon Member request. Additionally, if applicable to Plan benefits, Anthem shall
ensure that Members and potential Members have access to the BlueCard directory of Providers via a
website sponsored by BCBSA.
i. Anthem reserves the right to make benefit payments to either Providers or Members at its discretion.
Employer agrees that the terms of the Plan will include provisions for supporting such discretion in
determining the direction of payment including, but not limited to, a provision prohibiting Members from
assigning their rights to receive benefit payments, unless otherwise prohibited by applicable law.
j. If applicable to the Plan benefits and as indicated in Schedule B of this Agreement, Anthem may provide or
arrange for the provision of the following managed care services:
1. Conduct medical necessity review, utilization review, and a referral process, which may include,
but is not limited to: (a) preadmission review to evaluate and determine the medical necessity of
an admission or procedure and the appropriate level of care, and for an inpatient admission, to
authorize an initial length of stay; (b) concurrent review throughout the course of the inpatient
admission for authorization of additional days of care as warranted by the patient's medical
condition; (c) retrospective review; and (d) authorizing a referral to a non-Network Provider.
Anthem shall have the authority to waive a requirement if, in Anthem's discretion, such exception
is in the best interest of the Member or the Plan, or is in furtherance of the provision of cost
effective services under this Agreement.
Enterprise Administrative Services Agreement — October 2012 Master Template 4
City of Nashua 06/17/2013
